Going Out Of Network (OON) Is Likely TO Cost You More Money – And Maybe A Lot More
(Learn More About Your Rights and How the PWGA Can Help With OON Costs)
You may be aware that Out of Network providers will cost more – but you may be surprised by how much more. We want to protect you from that sticker shock, and if you still need to go Out of Network for services, there are tools the Health Plan has that can help.
OON providers can set any price they want for their services, regardless of what is considered reasonable and customary by the medical community.
The Health Plan reimburses 60% of a reasonable and customary amount, which is what In-Network (INN) providers charge.
Typically, this reimbursement is FAR LESS than what OON providers charge.
That means if a participant uses OON services, they have to pick up the difference – and that difference can be significant.
Here is a range of the prices OON providers have billed vs. the reimbursements allowed.
| Services | Amount Billed by OON | Reimbursement Allowed | Balance Owed by Participant |
| Office Visits/Lab Costs | $500 – $5,000 | $200 – $1,000 | $300 – $4,000 |
| Radiology/Rehab services | $5,000 – $40,000 | $300 – $2,000 | $4,700 – $38,000 |
| Surgeries/Infusion therapies | $50,000 – $180,000 | $400 – $5,000 | $39,000 – $175,000 |
Best Practices If You’re Going OON
There is an enormous potential cost associated with using Out Of Network medical services, while In Network providers are contractually bound to agreed-upon pricing.
If you are going to use an OON provider here is the best way to proceed:
- Check with the PWGA to make sure the procedure in question is a covered service. Ask about your personal cost exposure for the services if you are going to an OON provider. We are happy to assist you in determining a fair and reasonable price.
- Do not pay in advance for services or sign a document agreeing to pay the full amount. If you do, you may bear the full cost for amounts the PWGA does not cover. With providers who agree to bill after service, the Health Fund uses a service to price and negotiate claims, which may result in lower amounts for the Fund and participants.
- Ask the PWGA for help before agreeing to anything. The PWGA may be able to negotiate with the provider to achieve a lower price for you, but we can only do so if you have not already paid the provider.